OHCA is
suspending the requirement for inpatient facilities to obtain a prior
authorization request (PAR) for spinal fusion and/or discectomy procedures.
This change will be effective for surgeries performed on or after 3/1/2015.

However, the
surgeon, co-surgeon or assistant surgeon will continue to require PAR for
spinal fusions and/or discectomy procedures regardless of the place of
service.

In keeping
with our current process, surgeons are
required to submit the PAR, which must include the units and modifiers for both
the outpatient facilities as well as the name of any surgeon who
will need to file a claim. The PAR must include clinical documentation to
support the medical necessity of the requested services.

A standard print option is now available for
both the view and edit versions of your long term care cost reports. This
option allows you to print all schedules or individual schedules.

3/2/2015

Urine Drug Testing

Title:Urine Drug Testing

Run Date:02/18/2015 – 04/01/2015

PV Types:All

As a reminder, when performing urine drug testing, OHCA
letter 2014-36 advised providers specimen validity testing (SVT) is considered
a quality control measure and coverage is excluded. The NCCI Manual
supports this. Providers should not bill for SVT to confirm a urine
specimen is not adulterated. SVT includes the following:

-pH

-specific gravity

-creatinine

-nitrates

-oxidants

-urinalysis

2/9/2015

DME Webinar

Title:DME Webinar

Run Dates:02/09/2015-02/27/2015

PV Types:25; 250

OHCA
and HPES will be hosting a Durable Medical Equipment (DME) Webinar on Thursday
Feb. 26th at 2:00pm. This webinar will cover Fair Market
Value/Pricing Changes, Repair Changes (prior authorization and modifiers), and
Oxygen. This webinar is recommended for all SoonerCare DME providers/owners,
billing and prior authorization submission staff.

Effective 1/26/2015, Electroconvulsive Therapy services
(CPT 90870) will require prior authorization.Providers should fax ECT therapy requests and all supporting
documentation to (405) 530-7260. Please note, ECT requests will only be
processed during business hours.For
more information regarding this process, please direct questions to the
Behavioral Health Unit at (405) 522-7597.

1/21/2015

Behavioral
Health Transitional Targeted Case Management

Title:Behavioral
Health Transitional Targeted Case Management

Run Date:01/21/2015
– 02/28/2015

PV Types:11

Spc:110, 111, 114, 118

Behavioral Health Transitional Targeted Case
Management is now reimbursable for children transitioning from institutions to
the community during the last 30 consecutive days of a SoonerCare covered
institutional stay. For billing and prior authorization requirements, please
visit www.odmhsas.org/arc.htm or
contact the PICIS helpdesk at 405-521-6444 or gethelp@odmhsas.org.

1/21/2015

Nexplanon

Title:Nexplanon

Run Date:01/21/2015 –
02/28/2015

PV Types:All

Effective
2/1/2015:

Nexplanon®
will NO LONGER be available through the SoonerCare pharmacy benefit. Nexplanon®
will only be covered as a medical benefit. The physician or facility will need
to purchase the product. Once the Nexplanon® has been implanted then the
provider can bill SoonerCare for the product.

1/21/2015

Rho(D) Immune
Globulin Products

Title:Rho(D) Immune
Globulin Products

Run Date:01/21/2015 –
02/28/2015

PV Types:All

Global
Message for Rho (D) immune globulin Products

Effective
2/1/2015: The CPT codes 90384, 90385, and 90386 will NO LONGER be covered by
SoonerCare. These products should be billed using the appropriate HCPCS codes.
The NDC information is required when filing the claim using the HCPCS codes.
For more information on How To Use An NDC When Billing Physician
Administered Drugs please go
to the Billing & Procedure Manual webpage on our website (www.okhca.org).

1/13/2015

WEBINAR
- Introduction to Oklahoma SoonerCare Webinar

Title:WEBINAR
- Introduction to Oklahoma SoonerCare Webinar

Run Date:01/13/2015
– 01/23/2015

PV Types:All

OHCA and HPES
invite new billing agents, clerks and providers to attend an Introduction to
Oklahoma SoonerCare webinar on January 22nd at 2:30 p.m. The Introduction to
Oklahoma SoonerCare webinar will cover billing and procedural aspects of
Oklahoma SoonerCare. This training is not limited to specific provider types,
yet serves as a general overview of all aspects of the Oklahoma SoonerCare
program. Topics discussed will include covered services for adults and
children, exclusions, additional programs supported by OHCA and general policy
information. This webinar is recommended for all billing agents and billing
clerks new to Oklahoma SoonerCare.

OHCA
completed a beta round of external provider testing on August 29, 2014 and
will complete the first formal round (i.e., Round 1) of testing on
December 19, 2014. Currently, two additional rounds of testing are
scheduled as follows:

Round 2:
February 2, 2015 – April 30, 2015

Round 3:
June 1, 2015 – August 28, 2015

To
facilitate the next round of testing, OHCA will use the same approach as
that used for Round 1 and reach out to specific billing agents and
clearing houses to define which providers will be selected to participate
in the next round of testing. Each billing agent or clearing house will be
allowed to select no more than two of the providers for which they submit
claims for in production today.

It’s
recommended that providers contact their billing agent or clearing house
ASAP to let them know whether you’re interested in participating in
testing, and to see if they’re capable and willing to submit your test
claims if they’re contacted by HP to participate in the testing.

Due to the effort
involved to set up the billing agent or clearing house and provider
information in the test environment prior to the submission of test
claims, testing must be limited to approximately 10 to 20 billing agents
or clearing house per round of testing. This means that each round of
testing could encompass a total of 20 to 40 providers.

1/8/2015

Influenza Vaccines

Title:Influenza
Vaccines

Run Date:01/08/2015
– 02/20/2015

PV Types:All

Effective for
DOS 1/1/2015, billing for Influenza vaccines is as follows:

Medicare
claims for Influenze vaccine are submitted with the following HCPCS codes:

-Q2035 Afluria

-Q2036 Flulaval

-Q2037 Fluvirin

-Q2038 Fluzone

-Q2039
Influenza vaccine NOS

All
non-Medicare claims for Influenza vaccine are submitted with the following CPT
codes, based on the vaccine and definition:90654-90658, 90661, 90652, 90672, 90673, 90685-90688.

Influenze
vaccines furnished by the OSDH in the VFC program for the 2014-2015 Influenza
season can be located at this link.

Annually the
AMA and CMS review, add, change and delete various billing CPT and HCPCS
codes.It is OHCA’s annual standard
operating procedure to update our codes in accordance with our codified policy.
OHCA reminds all providers to be cognizant of new, changed and deleted 2015 CPT
codes and 2015 HCPCS codes for billing purposes. New codes are effective as of
January 1, 2015, date of service, and deleted codes are end dated effective
December 31, 2014.

12/23/2014

CPT
& HCPCS Codes RE Radiation Treatment

Title:CPT
& HCPCS Codes RE Radiation Treatment

Run Date:12/23/2014
– 02/06/2015

PV Types:All

For 2015, CPT and HCPCS codes
have changed related to Radiation Treatment planning and delivery. The
OHCA will follow ASTRO guidelines, allowing the following codes: CPT
77306, 77307, 77316, 77317 and 77318. Brachytherapy isodose planning CPT
codes 77316, 77317 and 77318 will be reimbursable. CPT 77401 will be allowed,
but 77402, 77407 and 77412 will end 12/31/14. In lieu of these CPT codes
for Radiation Treatment Delivery, use HCPCS G6003 through G6014 as appropriate
by definition of the code. Do not use CPT 77385, 77386 or 77387. In
lieu of these CPT codes, use G6016 or G6015. Use HCPCS G6001 or G6002 for guidance, based on
method. HCPCS G6017 is not reimbursable.

12/18/2014

2014
Flexibility Rule Changes

Title:2014
Flexibility Rule Changes

Run Date:12/12/2014
– 03/31/2015

PV Types:01-
Hospital

31-
Physicians

52-
State Employed Physicians

09-
Advance Practice Nurse

27- Dentist

10– Mid-level Practitioners

Providers
and hospitals affected by the delay in implementing a 2014 certified EHR
technology (CEHRT) may begin submitting attestations on December 18, 2014.
Attestations for the 2014 program year will be accepted through January 31,
2015 for hospitals and March 31, 2015 for eligible professionals. Please visit www.okhca.org/ehr-incentive for more information or contact us at
405-522-7347.

Pursuant to OAC 317:30-5-241,
30-5-276 and 30-5-281, effective 11/3/2014, all individual rendering outpatient
behavioral health providers are limited to billing no more than 35 hours per
week. Billable hours only include the time spent face-to-face with the client
providing treatment services.

This limit does not include
assessments, service plan development, psychological testing, or crisis
intervention.

This is notification that
starting November 5, 2014 we will be updating the claims editing system to
require the National Provider Identifier (NPI) of ordering or referring
providers on the following claims, for dates of services January 1, 2014 and
beyond.

If the billing provider type is Nutritionist,
Optician, Audiologist or if the billing
provider specialty is Speech Hearing Clinic, or Audiology Group
Diagnostic Sleep Study Clinic, DME Medical Supply Dealer, Sleep Medicine, or
Genetic Counselor and there is not an ordering/referring NPI on the claim, the
system will deny the claim.

11/3/2014

Sacral Nerve Stimulators

PV Types:All

Title:Sacral
Nerve Stimulators

Run Dates:10/31/2014
– 12/15/2014

As of November 1, 2014, the
placement, revision and removal of Sacral Nerve Stimulators will require prior
authorization (PA).This requirement
applies to both the test stimulation as well as the permanent
implantation of the device.Affected
procedure codes include:

•64595
Revision or removal of peripheral or gastric neurostimulator pulse generator or
receiver

For more information
regarding the PA process, please visit the Medical Authorization Unit web page
at www.okhca.org/mau, or contact the MAU at 800-522-0114.

10/30/14

Sleep Study Prior Authorization (PAR) Updates

Title:Sleep Study Prior Authorization (PAR) Updates

Run Dates:10/29/2014 – 11/30/2014

PV Types:All

Based on the short time since the onset of
Prior Authorization of Sleep Studies this summer, the OHCA has identified
problem areas and this global communication will address those issues in an
attempt to assist providers in efficient management of their PAR
resources.All clinical and
documentation requirements relating to sleep study PARs are recorded in the Sleep
Study Guidelines located on the public website:(http://www.okhca.org/providers.aspx?id=16427 ).

Covered
Indications:

Obstructive Sleep Apnea

Narcolepsy

Parasomnias (only where convincing
evidence is documented for danger to member or those around the
member)

Additional specific indications allowed for
children are included in the guidelines.

Non-Covered
Indications:Please do not submit PARs for non-covered
indications.

Insomnia is commonly submitted and is not
a covered indication.

Apnea of Prematurity is commonly submitted
and is not a covered indication.

Risk Factors- PARs are NOT approved based
on risk factors for a covered indication.

See guidelines for a listing of additional
non-covered indications.

Medical
Documentation Required for all Covered Indications:

History and Physical exam performed within
6 months

*Detailed sleep history with pertinent positives and negatives
(“snoring” is incomplete and not a detailed history)

*Specific physical exam of the airway
including pertinent positives and negatives for jaw, palate, tonsils; T
& A history or plan, etc.A Mallampati
score is very useful since it correlates with OSA;(“OP:MMM,”“OP:WNL,” are incomplete and are not an exam
of the airway)

*Epworth Scale for members 16 years of age
and older

Please see guidelines for specific requirements
for detailed sleep history and physical exam of the airway.

*= may be a part of the history and physical
exam or may be separate documents.

Procedural
Assistance:

If a split study (codes95811 or 95873) is requested and approved, and the member does not meet
the requirements of the split study, it can be continued as an overnight diagnostic.An amendment should then be filed
requesting approval of an overnight diagnostic (95810 or 95872).The approved 95811 then applies to the
titration done on the second night (the codes are the same).

For narcolepsy, the MSLT (95805) must be
preceded by an overnight diagnostic on the previous night.Please request both codes in the PAR.If the overnight makes the MSLT unnecessary,
just do not perform the MSLT and do not bill for it.

Requests for repeat testing must clearly
document the specific reasons for the repeated test.Please review and follow OHCA guidelines.

Paper PA Requests:

Assignment Codes on HCA-12A

46 Sleep Study (used by Sleep Centers) =
Section 4 must be completed

03 or 04 Dr. Office = No need to enter Section
4

If requesting modifier TC or 26, please include
a line for each of the modifiers.

Provider Portal Submissions:

Enter
each code as a separate line. Please
DO NOT use the “THRU” box.

10/30/14

REPOST/REMINDER/UPDATE

Medical Home ER Utilization Study Webinar

Title:REPOST/REMINDER/UPDATE

Medical Home ER Utilization Study Webinar

Run Date:10/13/2014 – 11/28/2014

Pv Types:08 – Clinic

10 – Mid-Level Practitioner

31 – Physicians

52 – State Employed Physicians

09 – Advance Practice Nurse

07 – Capitation Provider

Spc:080 – FQHC

081 – RHC

084 – I.H.S./Tribal Clinic

072 – I.H.S. Case Manager

093 – ARNP (Certified Nurse Practitioner)

100 – Physician Assistant

ATTENTION:SoonerCare Choice Primary Care Providers

The Oklahoma
Health Care Authority is conducting a study of current and potential emergency
department diversion models, for persons who are enrolled in SoonerCare that
may be implemented in the state, and to explore options for cost containment
and delivery alternatives that are consistent with the existing
Patient-Centered Medical Home program. From 4:00pm – 6:00pm on October 29th,and,
from 5:30pm – 7:30pmon November 5th
OHCA will be providing information regarding current ER utilization by
SoonerCare members covered through OHCA and will provide a channel for
participants to provide feedback, including recommendations, to OHCA on
reducing SoonerCare member ER utilization.

NOTE: These
WEBINARS will each be limited to the first 50 registrations. Click to Register

10/24/14

UPDATED: OHCA
Communications are Going Electronic

Title:
UPDATED: OHCA
Communications are Going Electronic

Run Dates:10/23/2014
– 12/10/2014

PV Types:All

REMINDER: Effective November 1, 2014, all communications
to providers will be through email distribution.

It is very important that your email address
be on your provider contract file. Read provider letter 2014-44 on our public
web site (www.okhca.org) for
instructions on updating your contract file.

Update (10/24/2014)

ATTENTION PROVIDERS
AFFILIATED WITH A GROUP CONTRACT: In order to
receive important policy and program information directly, you must add a
preferred email address to your individual
contract file. Otherwise, all official OHCA communications will only be sent to
the group administrator.

By ensuring that there is a
preferred email address in the individual contract file, both provider and the
group administrator will receive OHCA email communications.

10/23/2014

Reminder - OHCA Communications is Going Electric

Title:Reminder –
OHCA Communications is Going Electronic

Run Dates:10/23/2014 – 12/10/2014

PV Types:All

REMINDER: Effective November 1, 2014 all communications
to providers will be through electronic e-mail distribution.

It is very important that your e-mail address
be on your provider contract file. Read provider letter 2014-44 for
instructions on updating your contract file and accessing information on our Public
web site.

10/16/2014

Sleep Study Prior
Authorization Requests

Title: Sleep Study Prior
Authorization Requests

Run Date: 10/15/2014 –
12/01/2014

PV
Types: All

Effective immediately, prior authorization
requests (PARs) for sleep studies will no longer be reviewed on an urgent basis
by the Medical Authorization Unit (MAU). Because sleep studies are not
emergent, these PARs will be reviewed in the order of the date received.Currently, the MAU is processing sleep study
requests within five business days.You
may review the status of your PAR via the OHCA Provider Portal.

Thank you for the quality of care
that you provide to SoonerCare and Insure Oklahoma members. If you have
questions, please contact the OHCA MAU at 800-522-0114.

10/16/2014

New
ADA 2012 Dental Claim Form

Title:New
ADA 2012 Dental Claim Form

Run Date:10/14/2014-12/31/2014

PV Types:27
– Dentist

86
– Dental Clinic

271
– General Dentistry

272
– Oral Surgeon

273
– Orthodontist

274
– Pediatric Dentist

ATTENTION: ALL DENTAL PROVIDERS

OHCA will accept the American
Dental Association 2012 claim form effective 10-17-2014.

Effective 11/1/2014, Physician
review of claims with Headache diagnosis (339.00-346.73) will end. No clinical
attachments will be required.

10/13/2014

Medical Home ER Utilization Study Webinar

Title:Medical Home ER Utilization Study Webinar

Run Date:10/13/2014 – 11/28/2014

PV Types:08 – Clinic

10 – Mid-Level Practitioner

31 – Physicians

52 – State Employed Physicians

09 – Advance Practice Nurse

07 – Capitation Provider

Spc:080 – FQHC

081 – RHC

084 – I.H.S./Tribal Clinic

072 – I.H.S. Case Manager

093 – ARNP (Certified Nurse Practitioner)

100 – Physician Assistant

ATTENTION:SoonerCare Choice Primary Care Providers

The Oklahoma
Health Care Authority is conducting a study of current and potential emergency
department diversion models, for persons who are enrolled in SoonerCare that
may be implemented in the state, and to explore options for cost containment
and delivery alternatives that are consistent with the existing
Patient-Centered Medical Home program. From 4:00 pm – 6:00 pm on October 29th
and November 5th OHCA will be providing information regarding current
ER utilization by SoonerCare members covered through OHCA and will provide a
channel for participants to provide feedback, including recommendations, to
OHCA on reducing SoonerCare member ER utilization.

NOTE: These
WEBINARS will each be limited to the first 50 registrations. Click to Register

10/8/2014

VFC Processing Error/Recoupments

Title: VFC Processing Error/Recoupments

Run Dates:10/08/2014 – 11/22/2014

PV Types:All

OHCA is processing an adjustment for Medical
Homes and other vaccine for children (VFC) providers. Due to a processing
error, OHCA has been reimbursing for the vaccines that are provided free
through the VFC program since December 2012. This adjustment will recoup
those payments. Refer to provider letters 2009-20 and 2009-23 for further
clarification and accurate billing instructions. Providers can identify
these adjustments by EOB 8131 – “OHCA initiated offset due to processing
error”. These recoupments will be on providers’ October 22, 2014 remits.

10/3/2014

Clarification of Billing for CPT 95165 –

Preparation
of Allergy Antigen

Title:Clarification of Billing for CPT 95165 –

Preparation
of Allergy Antigen

Run Date:10/01/2014
– 11/15/2014

PV Types:All

Reimbursement
for CPT 95165 (professional services for the supervision of preparation and
provision of antigens for allergen immunotherapy; single or multiple antigens)
is based on the number of units of antigen(s) for allergen immunotherapy
contained in an original multi-dose vial (commonly referred to in the industry
as a maintenance or concentrate vial).The maximum reimbursement for any multi-dose vial is 10 units. A
unit is equal to a 1-cc aliquot antigen from an original multi-dose vial.Some antigens cannot be mixed together (i.e.,
they must be prepared in separate vials).An example of this is mold and pollen.Therefore, some individuals will require two (2) multi-dose vials to be
prepared and will receive injections prepared from both vials.

Reimbursement
limits are set at 10 units per original multi-dose vial per 90 days (20 units
per 90 days when it is medically necessary to prepare two (2) multi-dose vials)
and a total of 40 units (80 units when it is medically necessary to prepare two
(2) multi-dose vials) per 12 months, based on a rolling period.A prior authorization (PA) override may be allowed
for medically necessary indications.

For more
information regarding the PA process, please visit the MAU web page at www.okhca.org/mau and click on the section you would like to
review.

Modifier 52 is allowed/required
if only one coil is placed. This will result in a 50 percent reduction in
payment.

--------------------------------------------------------------

Should additional coils be
required, one (1) additional package mightbe
considered with prior authorization
(PA). This PA request should be submitted to OHCA’s Medical
Authorization Unit (MAU).

9/23/2014

OHCA External Provider Testing

Title:OHCA
EXTERNAL PROVIDER TESTING UPDATE

Run Dates:09/23/2014
– 11/07/2014

PV Types:ALL

Oklahoma
Health Care Authority External Provider Testing Update:

OHCA recently completed an
initial beta round of external provider testing on August 29, 2014.
Currently, three additional rounds of testing are tentatively scheduled as
follows:

Round 1: November 3,
2014 - December 26, 2014

Round 2: February 2,
2015 – April 30, 2015

Round 3: June 1, 2015
– August 28, 2015

OHCA is currently reaching
out to specific billing agents and clearing houses to define which
providers will be selected to participate in the next rounds of testing.
Each billing agent or clearing house will be allowed to select no more
than two of the providers for which they submit claims for in production
today.

It’s recommended that
providers contact their billing agent or clearing house ASAP to let them
know whether you’re interested in participating in testing, and to see if
they’re capable and willing to submit your test claims if they’re
contacted by HP to participate in the testing. You will only be selected
for testing if OHCA selects your billing agent or clearing house and they
in turn select you as one the two providers their allotted as noted in the
second bullet above.

For providers that would like
to be considered for testing who are ready to submit test claims but do
not use a billing agent or clearing house, and upload their own EDI
837 files, or enter claims directly, via the secure Provider Portal,
should send an email to the ICD-10 email account at: ICD10project@okhca.org indicating
their interest in testing. From the emails received, OHCA will select a
defined set of providers to participate in testing depending upon the
number of requests. In your email request to test with OHCA, please
include all pertinent contact information andwhich round of
testing you’d like to participate in. Pertinent contact information
would include:

SoonerCare Provider
number and location (e.g. 123456789A)

Name of organization

Name, email, &
phone number of the person responsible for ICD-10 testing

9/17/14

Clarification
Regarding Reimbursement for LBHP Candidates

Title:Clarification
Regarding Reimbursement for LBHP Candidate

Run Date:09/17/2014
– 10/31/2014

PV Types:11,
53

Spc:093, 100, 110, 111, 115, 117, 118, 119, 121

534,
535, 585, 586

Clarification Regarding Reimbursement
for LBHP Candidates

Effective 10/01/14, services
provided by LBHP candidates working for individually contracted LBHP providers
will no longer be reimbursable by SoonerCare. In order for LBHP candidates to
be reimbursed, they must provide services to clients through an outpatient
behavioral health agency. This change only affects SoonerCare reimbursement and
does NOT interfere with a licensure candidate's ability to choose from any
approved licensure supervisor and receive their licensure supervision in any
setting approved by their respective licensing board.

9/17/01

2014
Provider Workshop – Tulsa Registration Closing

Title: 2014
Provider Workshop – Tulsa Registration Closing

Run Date: 09/16/2014
– 10/23/2014

PV Types: All

Registration for the Sept 23rd & 24th, 2014 Fall
Workshop for Tulsa will close on Tuesday, Sept 16th at 5 p.m. However,
walk-ins are still welcome! Please come 15-20 minutes before the first class
you wish to take and bring your Provider ID.

Registration for locations in Lawton, Durant and OKC are
still available.

Each attendee must have their own registration and please thoroughly read the
class descriptions and recommended audiences before choosing your classes.
Register today!

Opioid painkiller quantity limits
will go into effect in the near future for all OHCA members. Learn how
this will affect your prescribing habits and practice at the OHCA the Fall
Provider Workshop! The class, conducted by Pharmacists, will focus on
opioid, narcotic and painkiller prescribing including upcoming SoonerCare
quantity limit restrictions. Next the patient review and restrictions
known as the Pharmacy Lock-In program will be reviewed along with the prior
authorization process for all medications covered by OHCA.

The
transfer of diabetic supply billing processing to the Pharmacy point-of-sale
method will no longer occur on October 1, 2014. This change has been
postponed.

OHCA
will issue a 60-day notice prior to implementing the change.

9/10/14

UPDATE:
2014 FALL TRAINING CLASS SCHEDULE

Title:UPDATE:
2014 FALL TRAINING CLASS SCHEDULE

Run Dates:09/08/2014 – 10/24/2014

PV Types:All

The
OHCA Provider Enrollment department will be conducting a class in the upcoming
Fall Provider Workshop! The class will cover how to update and maintain your
provider file as well as how to create a new contract or renew a contract.
There will be specific information for SoonerCare Choice and Insure Oklahoma providers
and behavioral health providers in a medical clinic. The class will also cover
OHCA’s new “Going Green” initiative. Workshops
will begin in Tulsa starting September 23rd!

Please note Page 6 of the guidelines which
lists the specific requirements for each of the three covered indications:
narcolepsy, obstructive sleep apnea and parasomnias where there is clear
evidence of danger to the member or others (and the diagnosis cannot be made
based on clinical evaluation).

Also, please note Page 7 of the guidelines. This
is where you will find a complete listing of what we do not cover,
unless the member has evidence of another covered indication. A few examples
are:

·Chronic
insomnia

·Restless
legs syndrome

·Circadian
rhythm sleep disorders

·Impotence

·Migraine
headaches

Effective September 15, 2014, incomplete PARs
for sleep studies will no longer be pended for additional information; they
will be cancelled. Additionally, the reason for the cancellation will be
indicated on the PAR.

If you need additional information about this
Global, please call the OHCA Provider Helpline at 800-522-0114. Specific
requests for onsite training should be directed to: ProviderServicesAdmins@okhca.org.

8/22/14

Oxygen Testing Exemption Process

Title:
Oxygen Testing Exemption Process

Run
Date: 08/21/2014-10/15/2014

PV
Types: 250 – DMEPOS Providers

There
is a new process for requesting oxygen testing exemption review.

Effective
August 25, 2014, such requests should be submitted to the Medical Authorization
Unit (MAU) as new prior authorization (PA) requests. PA for oxygen is not
required for SoonerCare members residing in nursing facilities.

Each
PA request requires the following:

1.HCA-13A special fax cover
sheet, if faxing your request. This must be the top document sent or the PA
request will be rejected by system;

2.HCA-12A PA form signed and
dated by the ordering provider; OR send an online request via the Provider
Portal secure site (no need to send the paper copy of HCA-12A for web
submissions);

3.RR modifier for oxygen
rental (not the LL)

4.Initial 90 days of service
are not subject to prior authorization.

5.If keyed online, a copy
of the signed orders must be attached to the uploaded documents; and

6.All signatures must be
legible or accompanied by a printed name with title.

7.Essential documents for
review:

Objective medical
records with sufficient documentation to support the member’s long-term needs
for service and the expectation that the medical condition requiring
oxygen will not improve;

Providers cannot bill or attempt to collect payment from a
SoonerCare Member for any covered service, other than co-payments allowed by
The Oklahoma Health Care Authority (OHCA).

Pursuant to 42 CFR 447.15, payments made by OHCA shall be
considered payment in full, except for OHCA allowed Member
co-payments. This provision is a part of all SoonerCare contracts and
applies even if the provider elects not to bill OHCA for a covered
service.

Any questions or concerns regarding balance billing should be
directed to Provider Services at 800-522-0114, option 1, before billing the
member.

8/7/14

SUD Treatment
Requirements

Title:SUD Treatment Requirements

Run Dates:08/04/2014 – 09/19/2014

PV Types:11

SPC:110,
118, 123

Pursuant to State
law, only facilities appropriately certified by the Oklahoma Department of
Mental Health and Substance Abuse Services (ODMHSAS) may receive and assist
alcohol and drug-dependent persons by providing treatment, recovery support and
rehabilitation. Organizations without proper certification may not provide
treatment services to clients with substance use disorder service focus. Any
claims for SUD treatment services provided by non-certified organizations are
subject to recoupment. For questions related to ODMHSAS certification please contact
Brenda Pitts at bpitts@odmhsas.org or
405-522-3800.

8/4/2014

Blood Glucose Testing Supplies

Title:Blood Glucose Testing Supplies

Run Date:08/01/2014 – 09/30/2014

PV Types:ITU – 07/072, 08/084

DME – 250

Physician – 31

Tribal Hospitals – 01/016

Physicians who
are treating members with pre-diabetes
symptoms may prescribe blood glucose (BG) testing supplies in accordance with
the member’s treatment. Dispensing providers would need to obtain a
prescription with the DX code of 79029 (Other Abnormal Glucose). Supply limits
for this group are identical to those for members who are diagnosed with Type 2
diabetes: two (2) boxes of 50 BG strips and one (1) box of 100 lancets per
quarter.

The telephone number specified originally in
Provider Letter 2014-13, [Therapy-Related Parental Participation – Effective
Date 08/01/2014] has been updated.

The new number to call with any questions is
(888) 693-3281, option 2. Thank you.

7/22/2014

WEBINAR: HOW TO SUBMIT A DENTAL PA ON THE
PROVIDER PORTAL

Title:WEBINAR: HOW TO SUBMIT A DENTAL PA ON THE
PROVIDER PORTAL

Run Date:07/22/2014 – 08/07/2014

PV Types:27 – Dentist

86
– Dental Clinic

271
– General Dentistry

272
– Oral Surgeon

273
– Orthodontist

274
– Pediatric Dentist

OHCA
will be conducting a WEBINAR on August 6, 2014 to review the process of
submitting Dental PA’s on the Provider Portal. This class will discuss the PA process, the
forms required, how to complete the forms properly and what records will be
required.

This
letter is to review the copays for individuals covered by the Insure Oklahoma
Individual Plan. As of January 1, 2014, co-pays for prescriptions, physician,
and outpatient visits were changed. Most copays are now $4, although some
prescriptions and durable medical equipment (DME) are $8. The emergency room
co-pay remains the same at $30 and is waived if the member is admitted. Current
co-pays are as follows:

For
dates of service on or after January 1, 2014, IO IP members are responsible for
paying all individual co-pay amounts for the aforementioned services. Please
review the remittance advice for total member co-pay amounts due. These changes
will not affect claims for dates of service rendered prior to January 1,
2014.

Thank
you for your continued service to Insure Oklahoma members. If you have
questions, please contact the Insure Oklahoma helpline at (888) 365-3742.

7/15/2014

Prior
Authorization Webinar for Spinal Fusion Surgery

Title:Prior
Authorization Webinar for Spinal Fusion Surgery

Run Date:07/15/2014
– 07/24/2014

PV Type:31-Physician;
01-Hospital

SPC:325 Neurological Surgeon

342 Thoracic Surgeon

544 Pediatric Orthopedics

551 Pediatric Surgery (Neurology)

559 Surgery Head and Neck

010 Acute Care

015 Children's
Specialty

Attention:
Neurosurgeons, Orthopedists and Inpatient Hospitals

Effective, July
2014, a new process will be implemented regarding the PA process for Inpatient
Spinal Fusion Surgery. We will be conducting webinars to go over the new
process on July 22 and July 24. This class will discuss the PA process,
the forms required, how to complete the forms properly and what records will be
required.

·have a history of psychiatric
hospitalization or admissions to crisis centers;

·have been determined disabled by the Social
Security Administration for mental health reasons;

·are residing in residential care
facilities; or

·are receiving services through a specialty
court program.

Children's
PSR services will be limited to members who have:

·a history of psychiatric hospitalization or
admissions to crisis centers;

·been determined disabled by the Social
Security Administration for mental health reasons;

·a current Individual Education Plan (IEP)
or 504 Plan for emotional disturbance; or

·been evaluated by a school psychologist,
licensed psychologist, or psychiatrist and determined to be "at risk.”

Guidance regarding prior authorization
requirements for these services will be provided in the next couple of weeks.
The Prior Authorization Manual will be updated to include the new processes and
added to the OHCA website (http://www.okhca.org) August 1.

Oxygen equipment and
services will require PA effective August 1, 2014. OHCA has determined
that prior authorizations will not be required for residents of nursing
facilities or Insure Oklahoma members; however, the modifier instructions below
apply to all claims.

All claims with dates of
service before July 31, 2014 will require the
use the “LL” modifier for oxygen equipment rental. HCPCS codes include E0424,
E0431, E0434, E0439, E1390, E1391, E1392, and K0738. The modifier “RR”
will be used beginning August 1, 2014.

No prior authorizations for
OXYGEN will be accepted by the OHCA system prior to August 1, 2014.

Provider
letters detailing these changes are forthcoming.

If
you have additional questions, please contact DME Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924.

If you have questions please
call the OHCA Call Center at (800)522-0114.

6/30/2014

NH Only Cost Share Reporting

Title:NH Only Cost Share Reporting

Run Date:06/27/2014 – 07/02/2014

PV Type:Nursing Homes:

03-Extended
Care Facility

SPC:

030

Nursing Facility

031

ICF/MR &gt; 6 Beds

032

Pediatric Nursing Facility

033

Residential Care Facility

034

ICF/MR &lt; 6 Beds

035

Skilled Nursing Facility

036

Respite Care - Facility Based

037

Assisted Living

Attention NH Facilities:

Effective July 2014, a new process will be
implemented in the Provider Portal regarding the submission of Cost Share
Reporting to the Oklahoma Health Care Authority. In this class, we will
discuss changes to the Cost Share Reporting for Long Term Care (LTC)
Providers. We will cover how to access the site and the various changes
in the actual reporting process. **-Attendees only need to register for one
webinar

Due to
administrative delays, the current processing method for manually priced items
will continue to be in effect until October 1, 2014. Please continue to
provide pricing information with your PA requests, if appropriate, or submit
costs with your claims as you do now.

Provider
Letters: A provider letter detailing these changes is
forthcoming.

If
you have additional questions, please contact DME Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924.

6/18/2014

NH Only Cost Share Reporting

Title:NH Only Cost Share Reporting

Run Date:06/18/2014 – 08/02/2014

PV Type:Nursing Homes:

03-Extended
Care Facility

SPC:

030

Nursing Facility

031

ICF/MR &gt; 6 Beds

032

Pediatric Nursing Facility

033

Residential Care Facility

034

ICF/MR &lt; 6 Beds

035

Skilled Nursing Facility

036

Respite Care - Facility Based

037

Assisted Living

Attention NH Facilities:

Effective July 2014, a new process will be
implemented in the Provider Portal regarding the submission of Cost Share
Reporting to the Oklahoma Health Care Authority. In this class, we will
discuss changes to the Cost Share Reporting for Long Term Care (LTC)
Providers. We will cover how to access the site and the various changes
in the actual reporting process. **-Attendees only need to register for one
webinar.

The RBRVS global dated June 12, 2014
mentioned the 7.75% rate reduction. For Behavioral Health services this
reduction only applies to psychiatrists and Inpatient Facility Psych Beds which
are paid off of the DRG fee schedule.

6/12/2014

New Fee Schedule

Title:New Fee Schedule

Run Date:06/12/2014 – 07/31/2014

PV Types: All

Remember that we update our fee schedule
every July to rebase to the new Medicare RVUs. The new fee schedule will be on
our public website as soon as possible.

Dates of service prior to July
1, 2014 are paid at last year’s rate and dates of service after July 1, 2014
are paid at the new rate. The new fee schedule will also reflect the
agency’s across the board rate reduction of 7.75%.

6/12/2014

DME Changes Effective 07/01/2014 - Blood Glucose Supplies

Title:DME Changes Effective 07/01/2014 - Blood
Glucose Supplies

Run Date:06/12/2014-07/31/2014

PV Types:250 – DMEPOS Providers

Blood Glucose Supplies

OHCA
will cover blood glucose (BG) supplies for members who are being treated with
insulin to allow a maximum of 100 per month. Coverage for BG supplies for
members who are not treated with insulin will be limited to 100 per a 90
days. In addition, OHCA will cover BG supplies for members who are
diagnosed with gestational diabetes, with a maximum allowable of 150 per month. Rates will be adjusted to national competitive bid
rates.

If
additional supplies are needed, BG supplies are eligible for prior authorization
(PA) override if documentation of medical necessity is provided to the Medical
Authorization Unit.

If you have additional questions, please contact DME
Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924

6/12/2014

DME Changes Effective 07/01/2014

Title:DME Changes Effective 07/01/2014

Run Date:06/12/2014-07/31/2014

PV Types:250 – DMEPOS Providers

Budget Impact – After thoughtful
consideration, the agency has determined that an across-the-board rate
reduction is required to balance the budget for the upcoming fiscal year.Therefore, a reduction rate of 7.75% will be
applied to all DME products.

Manually Priced Items

OHCA
will price items that do not have a set max fee rate, also known as manually
priced items, by examining the MSRP plus the invoice and paying the lesser of
MSRP -30 percent or cost +30 percent for those items. It will be
necessary for the provider to include a copy of the invoice, MSRP and proof of
delivery along with the claim when submitting for payment. In addition, the
7.75% Budget Reduction rate reduction will be applied to the claims for
manually priced items.

Oxygen

Oxygen
equipment and services will require PA effective July 1, 2014. All claims
after July 1, will require a new modifier RR(continuous rental) for oxygen rental. HCPCS codes include E0424, E0431,
E0434, E0439, E1390, and E1391.

If you have additional questions, please contact DME
Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924

6/2/2014

Medication/Pharmacy PAs

Title:Medication/Pharmacy PAs

Run Dates:05/30/2014 – 06/30/2014

PV Types:All

Medication/pharmacy prior authorizations
(PAs) should NOT be submitted via the provider portal; they will NOT be
processed. To properly submit, please visit www.okhca.org/rx-formsto make your PA request,
whether the drug is to be dispensed at a pharmacy or administered by a
physician.

The
rate for E0445 (Oximeter Device) for measuring blood oxygen levels non-invasively,
with rental episodes, will be changed from $120.94 to $193.50 for dates of
service after July 1, 2014. This rate increase includes the oxygen probes
(A4606) for use with the Oximeter Device during the rental period. After the
rental period is completed, additional probes may be obtained (up to a limit of
4 per month) if prior authorized.

5/19/2014

CPT Code 95165

Title: CPT Code 95165 (Preparation of vials for non-venom antigen)

Run Date:05/15/2014
– 07/01/2014

PV Types:All

Effective 06/01/2014,
reimbursement for CPT code 95165
(preparation of vials for non-venom antigen) will be limited to ten (10) doses
per multi-dose vial, in accordance with CMS guidelines.
If two multi-dose vials are used, provider may bill no more than 20
doses. If less than 10cc aliquot from multi-dose vial is used, provider may
bill only for number of 1cc aliquots.

The Oklahoma Health Care Authority (OHCA) continues to implement quality initiatives to support your patient care efforts for SoonerCare and Insure Oklahoma members. In line with this goal, the OHCA is implementing a therapy management program (TMP) for occupational therapy (OT), physical therapy (PT) and speech therapy (ST) in partnership with “MedSolutions and its affiliate Triad Healthcare” (“MedSolutions”), an organization that specializes in managing therapy-related services. This new process will allow the OHCA to assist our providers and members in obtaining the most appropriate therapy-related service and improve access to high quality, cost effective care in a timely manner.

For all OT, PT and ST services performed on or after July 1, 2014, treating providers will submit prior authorization requests (PARs) to MedSolutions.

To help with this transition, MedSolutions will be hosting webinar sessions at various times/dates. These sessions will provide you with all the information required for prior authorization and identify issues that may prevent you from obtaining a timely determination. For more information about participating in one of these webinars, please visit www.triadhealthcareinc.com/soonercare.

Because MedSolutions has a proven history of providing quality evidenced based review for therapy-related services, OHCA will be accepting their guidelines for use with all prior authorization reviews. MedSolutions will, however, continue to follow all of the OHCA’s general program requirements and payment/policies, including the current requirements for OT, PT and ST PARs (i.e. OT and PT evaluations may still be performed without prior authorization; however, ST evaluations must be prior authorized prior to rendering services).

MedSolutions is capable of processing all PARs within two (2) business-days; therefore, the 30-day Retro Rule will no longer apply and all OT, PT and ST services must be approved prior to rendering services. The one exception to the exclusion of the 30-Day Retro Rule will be for the month of July 2014. During this one-month period, after MedSolutions has begun processing therapy-related PARs for the OHCA, the 30-Day Retro Rule will remain in effect, ending on July 31, 2014.

Although school-based services are currently excluded from these changes, please be aware that in the coming months, the above-listed changes will apply to school-based services. Additional information will be released prior to implementing these changes for school-based services.

Thank you for the quality care that you provide to SoonerCare and Insure Oklahoma members. If you have questions, please contact the OHCA Medical Authorization Unit at 800.522.0114 or visit our website at www.okhca.org.

Adult Coverage for Optometry Services:Payment can be made for medical services that are reasonable and necessary for the diagnosis and treatment of illness or injury up to the patient's maximum number of allowed office visits per month.

There is no provision for routine eye exams, examinations for the purpose of prescribing glasses or visual aids, determination of refractive state, treatment of refractive errors, or purchase of lenses, frames, or visual aids. Payment is made for treatment of medical or surgical conditions which affect the eyes.

4/22/2014

HMO Copays on the New 1500 Claim Forms

Title: HMO Copays on the New 1500 Claim Forms

Run Date: 04/21/2014 – 06/07/2014

PV Types: All

To assist in the proper payment of HMO co-pay claims, the co-pay amount due should be entered in Block 24F and Block 29 on the “new”1500 form; failing to do so will result in a denial.

On the UB-04 form enter the co-pay amount in Block 47, the TOTALS block and Block 55B.

Please include the EOB or Roster with the corresponding co-pay. HMO co-pays should be filed for fully capitated plans only, not a PPO or Medicare Advantage Plan. These claims must be submitted on paper and mailed to: HP, PO Box 18500, Oklahoma City, OK 73154

4/18/2014

OHCA’s Position on ICD-10 Delay

OHCA’s Position on ICD-10 Delay

On Tuesday, April 1, 2014, President Obama signed Congressional Bill HR 4302 into law which delays the implementation of ICD-10 by at least one year, to October 1, 2015. As a result of the delay, the Oklahoma Health Care Authority will continue to accept only ICD-9 codes and deny any ICD-10 codes submitted on a claim until the Secretary of Health and Human Services formally adopts ICD-10 as the new ICD code set standard.

While the implementation of ICD-10 has been delayed, external testing with providers is still a top priority. Before defining the testing schedule however, OHCA is awaiting guidance from CMS regarding the delay. Once the testing schedule is finalized, it will be communicated accordingly.

4/14/2014

OP Surgery Referrals

Title: OP Surgery Referrals

Run Date: 04/10/2014 -05/29/2014

PV Types: All

In the previous referral system a specialist could use the referral from the SoonerCare Choice Primary Care Provider as approval for OP surgery that a member might need. Because of the unique way our electronic referrals are set in the system this passing along of a referral for OP services is not allowed. If the specialist feels the member needs OP surgery NO referral for the facility will be required. We have modified our system to bypass the referral requirement for OP surgery facility claims. If you have any additional questions please call the OHCA call center at 1-800-522-0114.

4/10/2014

2014 Provider Workshop – Enid Closing

Title: 2014 Provider Workshop – Enid Closing

Run Date: 04/09/2014 – 04/17/2014

PV Types: All

Registration for the April 17, 2014 Spring Workshop for Enid will close on Thursday, April 10th at 5 p.m. Registration for locations in OKC and Tulsa are still available.

It has come to our attention that Prior Authorization Requests (PARs) for SoonerCare members with the eligibility category of STBS-M have been auto-denying as no active benefits or not in active service.

If you have submitted a PAR for High Risk OB (HROB) services or Diabetic Supplies for an STBS-M member and received an auto denial, please contact us so the PAR can be manually processed.

Providers will need to call the main OHCA call center at 1-800-522-0114 and inform the call center representative that you have a PAR for HROB services or Diabetic Supplies, which auto-denied on an STBS-M member. The representative will then transfer you to the Medical Authorization Unit (MAU), at which time you will be prompted to leave a detailed message. An MAU representative will research the request and return your call within one (1) business day.

When prompted to leave a message, please provide the following information.

We are making modifications to the electronic referrals in the new SoonerCare Provider Portal. Because it needs additional modifications, both forms of referrals, electronic and paper, will be acceptable. Claims will process based on either form being used.

If the service you are addressing requires a Prior Authorization, this global message does not apply to your circumstance and an electronic referral or SC-10 form is not required for the Prior Authorization review.

We will let you know when only electronic referrals are to be used to request services.

3/24/2014

2014 Spring Provider Training Workshop

Title: 2014 Spring Provider Training Workshop

Run Date: 03/21/2014-05/16/2014

PV Types: All

PLEASE JOIN US FOR THE 2014 SPRING PROVIDER TRAINING WORKSHOP!You and your staff are encouraged to attend the Spring 2014 SoonerCare Provider Training Workshops hosted by the Oklahoma Health Care Authority (OHCA) and HP Enterprise Services. Classes offered will be Electronic Health Records (EHR), SoonerCare audits, Adjustments/Third Party Liability (TPL), Durable Medical Equipment (DME), and a class that will highlight the key features utilized on the new provider portal. These workshops will be held in 4 locations, beginning April 10th.

Durant, OK will be the first stop on April 10 followed by: Enid, April 17; Tulsa, April 30-May 1; and, conclude in Oklahoma City, May 14–15.

3/13/2014

REMINDER: New Paper 1500 Claim Forms

Title: REMINDER: New Paper 1500 Claim Forms

Run Dates: 12/20/2013 – 03/31/2014 extented through 04/30/2014

PV Types: All

OHCA will be able to accept the new paper 1500 forms starting January 6, 2014. We will be able to process both claim forms through March 31, 2014. Effective April 1, 2014 all 1500 claims filed must be on the new 1500 form regardless of the date of service.

Resiliency and psychiatric rehabilitation services are invaluable to children and their families. Increase your abilities and knowledge as a youth services practitioner by earning your Certificate in Children’s Psychiatric Rehabilitation (20 contact hours).

Effective 3/1/2014, CPT 92250 (fundus photography) is not covered for routine screening or typical refractive error diagnosis and is limited to one service annually.

2/27/2014

CPT Codes 65093 & 65105

Title: CPT Codes 65093 & 65105

RUN DATES: 02/27/2014 – 04/15/2014

PV Types: All

Effective 1/1/2014, CPT 65093 (Evisceration of Ocular contents, with implant) and CPT 65105 (Enucleation of eye, with implant, muscles attached to implant) age restrictions have changed to 0-999 years.

We have become aware that during recent Provider Training addressing the new Provider Portal, confusion was created regarding the PA Process handled by the Medical Authorization Unit (MAU).

The process for submitting a PAR to the MAU has not changed. We require the same information to be submitted, regardless of whether the request is submitted via fax or using the Provider Portal.

Required documentation:If you are entering a PAR via the Provider Portal, you will still need to submit the following:1. HCA-12A or a copy of the on-line PA Authorization screen or you may save a copy of this screen as a WORD document and attach it to the PA when you are uploading your documentation (The MAU staff are not able to view this information in our PA Workflow System).

For High Risk OB requests, the completed CH-17 form is still required.

Therapy PARs: The rendering/servicing provider should be the individual provider ID# or NPI of the therapist who will provide the services. Claims will not pay if a group ID is listed, as the individual licensed professional must file the claim.

2. The MAU requires a script or order from the treating provider for ALL PARs.

5. Photos can be scanned and upload in the same manner as uploading documents. Unfortunately, videos still require delivery via mail service.

We encourage you to use the Provider Portal to submit your PARs with the uploaded documents, as this reduces the potential for problems we have experienced in the past with providers faxing documents, especially legibility issues. For further information, please contact the MAU @ (800) 522-0114.

OHCA is now accepting email for patient volume documentation files at EHRDocuments@okhca.org. When sending the email, please include the provider’s name, NPI and ATN from the fax coversheet in the subject line. All emails should be sent securely when sending PHI. Please note the email is only to be used for patient volume documentation, you will still need to fax in the fax coversheet, signature page, vendor letter and meaningful use report to the fax number provided on the coversheet.

Reminder: The end date to submit your 2013 reporting year attestations is March 31st, 2014.

2/19/2014

Electronic Referral System Available Through the Portal

Title: Electronic Referral System Available Through the Portal

Run Date: 02/18/2014 – 04/03/2014

PV Types: All

As we are moving from paper referrals to the electronic referral system available through the portal, please keep in mind that the new system was only designed to replace the SC-10 form (paper referrals). The new referral will allow OHCA to track specialty utilization and allow claims to process. You will need to continue to send additional information that was requested from the specialist. This includes contact information for the members, face sheets, office notes etc. for continuum of care, for these members. Also, please note when submitting a new referral from the new provider portal, PCP’s should confirm the related NPI and address of the specific specialist that is being referred to. OHCA and HP are still reviewing ways to improve this new process. In conclusion, at this time paper referrals are still accepted through March 31st 2014.

Please be advised that due to issues regarding new OHCA provider portal, we will allow claims submissions up to 5:00 PM on Friday 01/31/2014. There will be no impact to the payment date. Thank you for your support as we continue to work through the issues related to the provider portal.

SoonerCare is now accepting Stage 2 attestations. CMS published a final rule that specifies the Stage 2 criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet in order to continue to participate in the Medicaid Electronic Health Record (EHR) Incentive Programs. If you have not participated in the Medicaid EHR Incentive Programs previously, or if you have never achieved meaningful use under the Stage 1 criteria, please visit www.okhca.org/ehr-incentive or contact us at 405-522-7EHR for more information about how to take part in the program.

1/16/2014

BH Portal Info/Required Security Enhancements

Title: BH Portal Info/Required Security Enhancements

Run Date: 01/16/2014 – 03/01/2014

PV Type: 08, 11, 53 Spc: 110, 111, 112, 115, 121, 193, 585, 535, 536

The provider portal will go live on January 24, 2014, our legal team as well as 45 CFR § 164.304, 164.306 and 164.312 of the Federal Health Insurance Portability and Accountability Act (HIPPA) requires security enhancements that will require all providers and submitters to manually log in and verify certain attributes to upload and download files. Some software on the market had created a script for auto populating security data to upload and download, this practice will no longer be allowed and was never approved by OHCA. In fact, OHCA advises that for your protection and ours, that you use each of the security functions to insure that PHI and your billing files are kept as secure as possible.

1/15/2014

Webinars: New Portal Training

Title: Webinars: New Portal Training

Run Dates: 01/15/2014 – 02/01/2014

PV Types: All

OHCA and HP Enterprise Services are excited to announce Webinar
training sessions. Webinars will address topics for certain provider
types that are relevant and timely for you and your staff. These
trainings will be hosted by HPES through HP Virtual Rooms and will last
approximately one hour.

Register now for these great interactive sessions! The 1500 and UB04
classes will be your last opportunity for training, before the new site
goes live!

Classes offered:

Recommended Audience: All SoonerCare providers, their staff, and billing entities that bill on a 1500 professional claim form.

Description: This class will introduce the new SoonerCare provider
portal to providers and entities who, currently, submit 1500
professional claims to the Oklahoma Health Care Authority. This class
will cover new and enhanced processes for claim submission, viewing
electronic remits, payment history and many additional features.

Recommended Audience: This is recommended to all SoonerCare
providers, their staff, and billing entities that bill on a UB-04 claim
form.

Description: This class will introduce the new SoonerCare provider
portal to providers and entities who, currently, submit UB-04 claims to
the Oklahoma Health Care Authority. This class will cover new and
enhanced processes for institutional UB-04claim submission, and many
additional features.

Recommended Audience: All SoonerCare Choice MH providers are strongly
encouraged to attend as well as specialty providers whose services
require a SoonerCare referral.

Description: This class will introduce providers to the new required
electronic referral process within the new SoonerCare provider portal.
It will cover how Medical Home (MH) providers will initiate specialty
referrals and how specialty providers will receive these referrals.
Medical Home providers are strongly encouraged to attend this class as
this process replaces the paper referral (SC-10) process beginning this
winter.

1/9/2014

New 1500 Claim Form Submissions

Title: New 1500 Claim Form Submissions

Run Date: 01/09/2014 – 02/24/2014

PV Types: All

OHCA is returning many 1500 [paper] Claim Forms to providers. The [new] 1500 Claim Forms are being printed/submitted with the [old] 1500 Form locators information; therefore, the information does not line up and cannot be processed.

Please ensure that all information is printed in the correct areas of the new 1500 Claim Form (02-12) to allow successful processing.

Unfortunately, OHCA systems have not been updated to agree with the exemption for Ordering/Referring NPI Requirement as of January 6, 2014 previously reported by OHCA and Waiver Advantage.

If your claim has “SUSPENDED” as the denial description; no further action is required by the provider. OHCA will reprocess claims in this category once the system fix is implemented.

If your denial is anything other than “SUSPENDED”; it will be necessary for you to reprocess the claim after you are notified of the system fix.

OHCA systems staff is working to correct this system edit and you will be notified as soon as it is implemented.

12/30/2013

REMINDER: New Paper 1500 Claim Forms

Title: REMINDER: New Paper 1500 Claim Forms

Run Dates: 12/20/2013 – 03/31/2014

PV Types: All

OHCA will be able to accept the new paper 1500 forms starting January 6, 2014. We will be able to process both claim forms through March 31, 2014. Effective April 1, 2014 all 1500 claims filed must be on the new 1500 form regardless of the date of service.

12/11/2013

TDaP Guidelines for Pregnant Women

Title: TDaP Guidelines for Pregnant Women

Run Date: 12/11/2013 -01/26/2014

PV Types: All

Recently, the Advisory Committee on Immunization Practices (ACIP) updated the guidelines for TDaP in pregnant women. The revised ACIP guidelines recommend that health care personnel administer a dose of TDaP during each pregnancy, irrespective of the patient’s prior history of receiving TDaP. To maximize the maternal antibody response and passive antibody transfer and levels in the newborn, optimal timing for TDaP administration is between 27 weeks and 36 weeks of gestation, although TDaP may be given at any time during pregnancy. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice supports these revised recommendations.

SoonerCare covers the TDaP vaccine through a member’s medical home or obstetrician’s office. The TDaP vaccine is also covered for SoonerCare members 19 years of age and older through the pharmacy benefit. A member can receive the vaccine at the health department as well.

12/5/2013

Webinar: Electronic Referrals (New Provider Portal)

Title: Webinar: Electronic Referrals (New Provider Portal)

Run Dates: 12/05/2013 – 12/13/2013

PV Types: All

HPES and OHCA will be conducting an Electronic Referrals (New Provider Portal) webinar on Dec 12th at 2:30pm. This webinar will introduce providers to the new required electronic referral process within the new SoonerCare provider portal. It will cover how Medical Home (MH) providers will initiate specialty referrals and how specialty providers will receive these referrals. Medical Home providers are strongly encouraged to attend this class as this process replaces the paper referral (SC-10) process beginning this winter. (This class will be limited to the first 150 registrants)

Effective January 1, 2014, Insure Oklahoma will allow only rental of the E0562 - Humidifier, heated, used with positive airway pressure device.

The prior authorization should be processed using the following guideline:

Submit PA for 3 months as rental – use LL modifier

Submit PA for convert to Purchase – do not use LL modifier (9 x $19.05= $171.45)

Submit claim for exact amount - $171.45

CPAP’s and Humidifiers are eligible for convert to purchase at month 4 only – the purchase option does not apply to BIPAP’s.

Future prior authorizations will not be approved for purchase – only rental. If you have any questions, contact Stan Ruffner, DME Director at 405.522.7924.

12/2/2013

Changes in Speech Evaluation Codes

Title: Changes in Speech Evaluation Codes

Run Date: 12/02/2013 - 01/17/2014

PV Type: Speech/Hearing Therapist (173); Speech Hearing Clinic (182)

Effective January 1, 2014, CPT code 92506 (speech – language evaluation) is being replaced by new, more specific codes. Please refer to the CPT manual for the proper codes for utilization. The last date of service for CPT code 92506 claims will be December 31, 2013. Because of these changes, authorizations for CPT code 92506 will end on December 31, 2013. For all speech PA-related questions, please call the OHCA Call Center at 800-522-0114.

11/25/2013

Mandatory Integration of BH Screenings

Title: Mandatory Integration of BH Screenings

Run Dates: 11/25/2013 – 01/05/2014

PV Types: All

To all Choice providers

You were notified of changes to your Choice contract in October. It involves mandatory integration of Behavioral Health Screenings into your medical home processes for member 5 and above.Please let us know if you did not receive this notification by e-mailing Provider Services Admins: ProviderServicesAdmins@okhca.org . We will send you another copy for your files.

Also be aware that Physician Assistants and Advance Nurse Practitioners who are Choice providers must have their DEA and OBNDD on file as part of the contracting approval process.

Please call the OHCA call center for questions related to contracting at 1-800-522-0114.

11/22/2013

New Paper 1500 Claim Forms

Title: New Paper 1500 Claim Forms

Run Dates: 11/21/2013 – 01/06/2014 And: 12/20/2013 – 03/31/2014

PV Types: All

OHCA will be able to accept the new paper 1500 forms starting January 6, 2014. We will be able to process both claim forms through March 31, 2014. Effective April 1, 2014 all 1500 claims filed must be on the new 1500 form regardless of the date of service.

11/15/2013

Webinar: PA Submission (New Provider Portal)

Title: Webinar: PA Submission (New Provider Portal)

Run Date: 11/15/2013 – 11/22/2013

PV Types: All

On Thursday November 21st HP will present the Prior Authorization Submission (New Provider Portal) class at 2:30 p.m. These webinars will cover the same information as the Spring/Fall workshops for those that were unable to attend.

All SoonerCare providers and their staff that submit DME and medical prior authorizations are encouraged to attend.(PT, OT, ST, surgical, etc.).This class will guide providers through the new process of submitting medical and DME prior authorizations on the new SoonerCare provider portal. This will be a step-by-step guide on the submission process only- this will not include any discussion over approval criteria or prior authorization policy. This class is not for behavioral health, pharmacy or dental providers. (This class will be limited to the first 125 registrants)

Note: For multiple users per provider office, please incorporate a conference room or work station set up (using one registrant and conference line) this will increase the efficacy of our training and accommodate more providers per webinar.

Due to the overwhelming response and attendance for the 2013 Spring and Fall Workshops that introduced the new provider portal, HP and OHCA will be conducting webinars to assist providers in getting this important training.

On Thursday November 7th, HP will present the 1500-Professional Claim Submission for the New Provider Portal at 2:30 p.m. These webinars will be limited to the first 125 registrants.

Note: For multiple users per provider office, please incorporate a conference room or work station set up (using one registrant and conference line) this will increase the efficacy of our training and accommodate more providers per webinar.

Due to the overwhelming response and attendance for the 2013 Spring and Fall Workshops that introduced the new provider portal, HP and OHCA will be conducting webinars to assist providers in getting this important training.

On Thursday October 31st HP will present the Access and Eligibility class at 2:30 p.m. These webinars will be limited to the first 100 registrants.

Note: For multiple users per provider office, please incorporate a conference room or work station set up (using one registrant and conference line) this will increase the efficacy of our training and accommodate more providers per webinar.

Flu season is here, and as a provider for our SoonerCare members we wanted to remind you of our coverage for this very important preventive service.

Children’s coverage:The flu vaccine is supplied by the Health Department through the Vaccine for Children’s program. Therefore SoonerCare Choice Primary Care Providers will be reimbursed for the administration only.

All other SoonerCare providers will be reimbursed for the vaccine and the administration.

Adult coverage including Soon to be Sooners members: OHCA will reimburse for the vaccine and the administration.If an adult has a valid prescription from a provider they can receive their flu vaccine at a local pharmacy. We pay the cost of the vaccine and the dispensing fee.

According to the approved State Plan, facilities late in filing the long term care cost report may lose the direct care component of their rate which ranges from $14.02 to $29.91 per patient day. Full year Reports are required to be filed on the secure website and partial year reports are required to be filed on the form available on the OKHCA website: www.OKHCA.org

10/14/2013

Registration for OKC Fall Training

Title: Registration for OKC Fall Training

Run Date: 10/14/2013 – 10/25/2013

PV Type: All

Registration for the Oklahoma City Workshop on October 23rd and 24th will close today at 5 pm. If you are registered for this workshop, please make every effort to attend. These are important trainings that are relative to all providers who are currently using the SoonerCare Secure Site. Most classes in OKC are full, therefore walk-ins will be extremely limited and not guaranteed. If you were unable to register for this workshop, please watch your global messages for additional training opportunities.

The Oklahoma Health Care Authority is updating the global of 6/17/13 regarding the authorization process for home infusion therapy for Antibiotic, Antiviral and Antifungal for Dual Eligible members only. **Please note #5 is now required effective 10/15/2013. All PA requests received as of this date that do not include a CMN (HCA-29) will be cancelled. S9494 – Home infusion therapy, antibiotic, antiviral or antifungal therapy; administration services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately, per diem).

Medicare Part D:

Effective July 1, 2013, providers serving members with Dual Eligibility benefits (Medicare Part D) will be required to submit the following for a Prior Authorization using the S9494 code:1. HCA-13A Prior Authorization Fax Cover Sheet2. HCA12-A Prior Authorization Form3. Prescription detailing the orders, including duration of treatment4. Medicare D Billing Response showing payment for the drug 5. HCA-29 OHCA Certificate of Medical Necessity External Infusion Pump is required per OHCA Policy (update 10/4/2013) (***Medical records are NOT REQUIRED to be submitted for Medicare Part D)OHCA will no longer cover the monthly pump rental (E0781 or E0791) for these medications nor the supplies (A4221 or A4222) starting July 1, 2013.Medicare Part B: please continue to file with Medicare.Title XIX: Continue to follow the current process for Prior Authorizations.For all DME/Medical Prior Authorizations related questions, please contact the Medical Authorization Unit at 1-800-522-0114.

10/4/2013

DMEPOS Provider Contract Renewal Period Open Now

Title: DMEPOS Provider Contract Renewal Period Open Now

Run Date: 10/04/2013 – 11/19/2013

PV Type: 250 – DME/Medical Supply Dealers

DMEPOS CONTRACTS ARE EXPIRING JANUARY 31, 2014. THE ELECTRONIC PROVIDER ENROLLMENT APPLICATION WILL BE AVAILABLE ON THE SECURE WEBSITE AS EARLY AS 10/7/13.

REMINDER – WHEN SUBMITTING YOUR RENEWAL CONTRACTS, YOU MUST FAX A COPY OF YOUR PROOF OF ACCREDITATION, YOUR MEDICARE EXEMPTION LETTER; OR A LETTER ADDRESSED TO OHCA REQUESTING AN EXEMPTION FROM THE ACCREDITATION REQUIREMENT. SEE THE EXEMPTION LIST THAT IS POSTED ON THE PUBLIC WEBSITE AT WWW.OKHCA.ORG.

BEGINNING WITH THIS RENEWAL PERIOD, OHCA POLICY REQUIRES THAT DMEPOS PROVIDERS MUST HAVE A PHYSICAL LOCATION IN THE STATE OF OKLAHOMA OR REQUEST AN EXCEPTION TO THIS REQUIREMENT. PROVIDER CONTRACTS FOR OUT OF STATE DMEPOS PROVIDERS WILL BE REVIEWED ON A CASE-BY-CASE BASIS. THE OHCA HAS DISCRETION AND THE FINAL AUTHORITY TO APPROVE OR DENY ANY PROVIDER CONTRACT.

PLEASE USE THE EMAIL FIELD TO UPDATE YOUR PROVIDER FILE WITH THE EMAIL ADDRESS OF YOUR COMPANIES’ CONTRACT MANAGER

YOU MAY CONTACT STAN RUFFNER AT stan.ruffner@okhca.org if you have specific question about exemptions. Otherwise, please contact Provider Enrollment at 800.522.0114 Option 5.

9/30/2013

Tulsa & OKC 2013 Fall Training Workshops

Title: Tulsa & OKC 2013 Fall Training Workshops

Run Dates: 09/30/2013 – 10/28/2013

PV Types: All

Registration for the Tulsa Workshop on October 9th and 10th will close October 2nd at 5:00 pm. The registration for OKC is still open; however, most classes are full. If you are registered for the Tulsa or OKC workshop, please make every effort to attend. These important trainings are relative to all providers who are currently using the SoonerCare Secure Site.

The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released by the American Psychiatric Association (APA) in May 2013. In order to comply with the APA’s request for insurers to implement the new changes by the end of the year, OHCA and the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) plan to accommodate the DSM-5 by 1/1/2014. The only changes that will impact your daily practice are related to the prior authorization process and fields on the CDC. PICIS will still require diagnoses, but there will be five open diagnoses fields instead of splitting between axis 1 and 2. Axis 4 questions will no longer be required, and will not be visible in PICIS. At provider requests, we will leave the Axis 3 diagnosis field to allow providers to still record medical issues with the customer. DSM-5 was created to cross- walk with both ICD-9 and ICD-10, so there should be no implementation issues when ICD-10 is implemented in late 2014.

For inpatient behavioral health providers, the only impact to you will be related to the inpatient clinical templates that are submitted by your utilization review department. New revised templates will be posted on OHCA’s website by December 01, 2013 for use beginning January 01, 2014.

If you have any questions, please contact Provider Services at (877)823-4529 option 1.

9/17/2013

Registration for Lawton SC Provider Workshop

Title: Registration for Lawton SC Provider Workshop

Run Date: 09/17/2013 – 10/25/2013

PV Type: All

Registration for the Lawton SoonerCare Provider Workshop on September 26th will close Thursday Sept 19th at 5 pm. Classes are filling up quickly, therefore walk-ins will be limited in Lawton and on a first come, first serve basis. (Walk-in registrations are not guaranteed.) The registrations for Tulsa(Oct 9 & 10), and OKC (Oct 23 & 24) are still open; however, many classes are full. If you are registered, please make every effort to attend. These are important trainings that are relative to all providers who are currently using the SoonerCare Secure Site.

On September 24, 2013, the HP EDI department will be presenting a webinar over the NPI Crosswalk for Oklahoma SoonerCare Electronic Claims. The Webinar was created to provide information on the SoonerCare solution to the NPI crosswalk and to assist providers in resolving their NPI crosswalk claim denials. We will discuss how to crosswalk an NPI number to the appropriate Medicaid billing or rendering legacy provider id number utilizing additional information, such as zip+4, contract code and taxonomy code. The NPI Crosswalk for Medicare Crossover claims will not be discussed in this presentation. (Class is limited to the first 100 registrants)

Target Audience: SoonerCare Providers, billing agents, clearinghouses and software vendors who are currently uploading claims electronically (NOT submitting claims directly on the SoonerCare secure website) and have a desire to learn more about Oklahoma Medicaid NPI Crosswalk are encouraged to attend this webinar.

Registration for the Durant SoonerCare Provider Workshop on September 16th will close today at 5:00 pm. Classes are filling up quickly, therefore walk-ins will be limited in Durant and on a first come, first serve basis. (Walk-in registrations are not guaranteed.) The registrations for Lawton, OKC, and Tulsa are still open; however, many classes are full. If you are registered, please make every effort to attend. These are important trainings that are relative to all providers who are currently using the SoonerCare Secure Site.

Effective 7/1/13, OHCA will no longer allow reimbursement for J1642, heparin lock flush. CMS considers this service integral to the procedures billed when a member has a port for IV access. Heparin flush is not separately billable.

Consistent with the recommendations set forth by ACMG and ACOG, OHCA considers CF carrier screening using the common mutation panel (CPT code 81220) to be medically necessary once in a lifetime for women of reproductive age and the partners of those that test positive. Expanded mutation panels beyond those recommended by ACMG/ACOG are not considered medically necessary and will be reimbursed at a rate that is based on the common variant panel alone.

OHCA does not consider other carrier screening in the general population to be medically necessary. In particular, carrier screening for Fragile X (CPT code 81243) and SMA (CPT code 81401) are not considered medically necessary in the absence of a family history suggestive of those conditions. This is consistent with the ACOG and ACMG recommendations for Fragile X carrier screening and the ACOG recommendations for SMA carrier screening.

Effective for prior authorizations submitted after October 1, 2013 for selected enteral nutritional products; providers may use the prices listed on the worksheet posted on the DME website located at www.okhca.org. The worksheet is located under the PRICING tab.

For prior authorizations submitted after October 1, 2013; invoices will not be required when the product is listed on this report. The PA will be priced using this report. If the product in question is not on this list, providers must submit an invoice showing cost with the PA request.

The report will be updated quarterly – if you have an addition or correction, send to stan.ruffner@okhca.org with the product description, NDC, Manufacturer Product Code and changes will be made if deemed appropriate.

8/5/2013

Webinar re: Speech Therapy Prior Authorization Requests

Title: Webinar re: Speech Therapy Prior Authorization Requests

Run Dates: 08/01/2013 – 08/23/2013

PV Types: All

The OHCA Medical Authorization Unit will be presenting a webinar for Speech Therapy Prior Authorization Requests. This webinar will review the Prior Authorization process for Speech Therapy, including required documentation and clarification of the 90-day timeframe. The recommended audience would be any SoonerCare provider, including Speech Therapy Providers, needing an overview of the PA submission process for Speech Therapy. This webinar will be limited to the first 100 registrants. We look forward to seeing you.

Due to efforts to insure medical necessity is documented for use of Orthotic devices, OHCA has place reasonable limits on the Orthotic HCPCS codes (L0100-L4999) effective July 1, 2013. You can access the utilization limits on the public website at www. Okhca.org under the Provider Type – DME tab.

Policy 317:30-5-211.13 Prosthetic & Orthotic devices indicates that …There is no coverage of orthotics for adults.

All items in this classification are eligible for a PA override if the utilization limit has been reached in the past 12 months – an HCA 12A indicating the medical necessity for the additional product along with any growth measurements that will support the need is necessary for the MAU staff to review for appropriateness.

This change will allow for medically necessary Orthotic products to be replaced prior to the one year limit if prior authorized. Contact Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org if you have any questions about this change.

Effective July 1, 2013 outpatient behavioral health services fee schedules for private Psychologists and Licensed Behavioral Health Professionals (LBHPs) were revised to reflect annual updates to the Medicare fee schedule. The current fee schedules can be located by visiting www.okhca.org/behavioral-health. These rates are effective for claims with dates of service on and after July 1, 2013.

7/23/2013

Audiology Students

Title: Audiology Students

Run Date: 07/23/2013 – 09/05/2013

PV Type: 20 Audiologist SPC 200 Audiologist

The purpose of this announcement is to give additional guidance on services provided by audiology students. Per OAC 317:30-5-675 SoonerCare eligible speech and hearing providers must be either state licensed speech/language pathologist or state licensed audiologist.

Audiology students are not qualified SoonerCare providers, therefore services rendered by a student will not be reimbursed. However, an audiology student may participate in the rendering of the service as long as the qualified, licensed audiologist is:

• Present and in the same room, one-to-one with the student for the entire audiology session; and• Guiding the delivery of services; and• Making the skilled judgment; and • Is not engaged in treating another patient or performing another task at the same time.

The qualified practitioner is responsible for all services and all documentation. Students may assist in the completion of the documentation and sign the documentation. However, the qualified practitioner must co-sign the documentation, which includes a signed personal attestation. In this attestation, the practitioner must attest to his/her presence and participation during the services, and the completion and accuracy of the audiology assessment, treatment plan, and services rendered.

7/23/2013

New Fee Schedule

Title: New Fee Schedule

Run Date: 07/23/2013 - 09/05/2013

PV TYPES: All

Remember that we update our fee schedule every July. The new fee schedule is on the web.

Dates of service prior to July 1, 2013 are paid at last year’s rate and dates of service after July 1, 2013 are paid at the new rate.

When transportation services are not covered by Medicare and the destination is to the ER, an appeal from Medicare is no longer required. Send the completed HCA-17 form, along with the claim form and the Medicare EOB showing the denial reason to: Attn: Provider Services Oklahoma Health Care Authority PO Box 18506, Oklahoma City, OK 73154.

The first quarter Jan–Mar claims for ACA qualified primary care providers as well as all the vaccine administration claims for kids will be paid on your 7/24 remits. The second quarter Apr–Jun claims for ACA qualified primary care providers will be paid on your 7/31 remits. The EOB code for the enhanced payment is 8147 and the EOB code for vaccine administration is 8155.

7/12/2013

Sign-Up for Web Alerts

Title: Sign-Up for Web Alerts

Run Dates: 07/11/2013 – 08/25/2013

PV Types: All

To make sure you get updates related to the SoonerCare program please sign up for web alerts on our public website. Especially important is the Provider Letter page. Anyone can sign up for web alerts so multiple members of your staff can receive the updated information.

In addition to that method of communication, all of our provider letters are sent electronically. Please log onto the secure site and update your e-mail on your contract file. This will provide another way to have up to date information about SoonerCare.

Effective immediately, OHCA has implemented a revised “DEN-3, Dental Provider Change Form”. The form is located on the public website in the “Forms” section. Please replace any old forms you may have on hand. Please note a parent/guardian signature & contact phone is now required for all change of provider requests/transfers. The new rendering dentist will also need to sign the form. This must be completed and faxed to OHCA prior to services rendered. Thank you for your continued support to SoonerCare members, and your cooperation in this matter.

6/17/2013

Home Infusion Therapy – Antibiotic, Antiviral and Antifungal

Title: Home Infusion Therapy – Antibiotic, Antiviral and Antifungal

Run Date: 6/17/2013 – 7/31/2013

PV Types: DME/Medical Supply Dealers 250

The Oklahoma Health Care Authority has revised the authorization process for home infusion therapy for Antibiotic, Antiviral and Antifungal for Dual Eligible members only.

Medicare Part D:Effective July 1, 2013, members with Dual Eligibility benefits (Medicare Part D) will be required to submit the following for a Prior Authorization using the S9494 code:1. HCA-13A Prior Authorization Fax Cover Sheet2. HCA12-A Prior Authorization Form3. Prescription detailing the orders, including duration of treatment4 Medicare D Billing Response showing payment for the drug

(***Medical records are NOT REQUIRED to be submitted for Medicare Part D)OHCA will no longer cover the monthly pump rental (E0781 or E0791) for these medications nor the supplies (A4221 or A4222) starting July 1, 2013.

Medicare Part B: please continue to file with Medicare.

Title XIX: Continue to follow the current process for Prior Authorizations.

The purpose of this announcement is to give additional guidance on provider letter OHCA 2013-05, dated February 14, 2013 and OHCA policy regarding the prior authorization (PA) process for Speech and Language Pathology services. OHCA policy OAC 317-30-5-676 states “All therapy services, including the initial evaluation, must be prior authorized. Prior to the initial evaluation, the therapist must have on file a signed and dated prescription or referral for the therapy services from the member's physician or other licensed practitioner of the healing arts. The prescribing or referring provider must be able to provide, if requested, clinical documentation from the member's medical record that supports the medical necessity for the evaluation and referral.” Other licensed practitioner of the healing arts refers to PAs, ARNPs or CNSs. The intent of this policy language is to assure that all referrals or orders for therapy services are written and signed by the member's treating provider (i.e. Physician, PA, ARNP or CNS). We are informing SLP providers that the referring or ordering provider, whether a physician, PA, ARNP or CNS, must be actively treating the member for which the services are being requested.

To insure the referral or order is generated from a provider actively treating the member and that the services are medically necessary, effective immediately any new PA request submitted to the OHCA Medical Authorization Unit will only be considered if submitted with clinical documentation from the member’s treating provider, which supports the medical necessity for the services requested. Any PA request submitted prior to this date will not require this treating provider documentation in order to be considered, however OHCA may still ask for it if necessary to support medical necessity.

Additionally, referrals or orders will be considered valid for a maximum of 90 days, i.e. the PA request must be submitted with a signed referral or order no older than 90 days.

If you have additional questions please contact the Medical Authorization Unit at 1-800-522-0114.

6/4/2013

Provider Portal – “Go Live” Delay

Title: Provider Portal – “Go Live” Delay

Run Date: 06/04/2013 – 07/19/2013

PV Types: All

To allow for additional testing, enhancements and training of providers for the new provider portal, OHCA will delay the “Go Live” date until the Fall of 2013.

Providers should continue to watch their global messages and the OHCA training page for updates and training opportunities.

5/29/2013

Registration for May 30th Webinar

Title: Registration for May 30th Webinar

PV Types: All

Run Date: 05/29/2013 – 05/30/2013

Due to the overwhelming response and attendance for the 2013 Spring Workshops that introduced the new provider portal, HP and OHCA will be conducting webinars to assist providers in getting this important training. We understand that many of these classes filled up quickly and some providers were unable to attend the onsite trainings.

Therefore, on May 30th we will hold our first webinar for these popular classes. The MAU (Prior Authorization Submission) Presentation will be held at 2:30 p.m. These webinars will be limited to the first 100 registrants.

Note: For multiple users per provider office, please incorporate a conference room or work station set up (using one registrant and conference line) this will increase the efficacy of our training and accommodate more providers per webinar.

The FFY13 third quarter Disproportionate Share Payment (DSH) scheduled for the June 5, 2013 remit will be paid on the June 12, 2013 remit.

5/22/2013

FFY13 3rd Quarter Disproportionate Share (DSH) Payment

Title: FFY13 3rd Quarter Disproportionate Share (DSH) Payment

Run Date: 05/22/2013 – 07/07/2013

PV Types: All

The FFY13 third quarter Disproportionate Share Payment (DSH) scheduled for the June 5, 2013 remit will be paid on the June 12, 2013 remit.

5/13/2012

Registration for 2013 OKC Spring Workshop

Title: Registration for 2013 OKC Spring Workshop

PV Types: All Providers

Run Date: 05/13/2013 – 05/21/2013

The Tulsa Workshop registration on May 22nd and 23rd is now closed and all classes are full. As a reminder, you must be pre-registered to attend and WALK-IN REGISTRATION WILL NOT BE AVAILABLE.

For more information and training opportunities about the new provider portal, please continue to watch your global messages and the OHCA Provider Training page.

5/8/2013

Registration for 2013 Tulsa Spring Workshop

Title: Registration for 2013 Tulsa Spring Workshop

PV Types: All Providers

Run Date: 05/08/2013 – 05/21/2013

Limited classes remain for the Tulsa Workshop on May 22nd and 23rd; however, registration is still open and will close Friday May 10th at 5:00pm. Each attendee must have their own registration and please thoroughly read the class descriptions and recommended audiences before choosing your classes.

For more information and training opportunities about the new provider portal, please continue to watch your global messages and the OHCA Provider Training page.

4/23/2013

SoonerCare Dental 101 Webinar

TITLE: SoonerCare Dental 101 Webinar

Run Date: 04/24/2013

PV Types: All

PLEASE JOIN US FOR THE SOONERCARE DENTAL 101 WEBINAR TOMORROW APRIL 25TH!

OHCA and HPES will host a webinar/conference call for all dental providers. This webinar will focus on submission of current dental prior authorizations and general dental policy. This webinar will not cover the new enhanced provider portal. The recommended audience would be all SoonerCare Dental Providers.The webinar will take place via online virtual room and conference call on April 25th at 2:30.

Please register to take part in this great webinar before 5pm on Wed 4/24/13.

Registration for the Oklahoma City Spring Workshop on May 8th and 9th will close April 22nd at 5 p.m. The OKC workshop is full and we will not be able to take walk-in registration. Some classes remain open for the Tulsa Workshop on May 22nd and 23rd. Each attendee must have their own registration and please thoroughly read the class descriptions and recommended audiences before choosing your classes. Register today!

In follow up to our global message related to enrollment system upgrade, 4/12-4/15-2013. The NB-1 application continues to be unavailable. We are making necessary changes to restore this application. We will send an update when the system is ready to go. Remember all babies will be added to the eligibility system with an effective date of their date of birth.Thank you for your patience.

4/11/2013

SoonerCare Dental Webinar

Title: SoonerCare Dental Webinar

Run Date: 04/10/2013 – 04/24/2013

PV Types: 27 – Dentist

The OHCA Dental unit will be offering a SoonerCare Dental 101 class on April 25, 2013 at 2:30pm. All SoonerCare Dental providers are encouraged to attend. The class will focus on submission of dental prior authorizations and general dental policy.

Beginning at 12:01 am on April 12, 2013 the enrollment system will be down. We are enhancing the enrollment software to improve the member and provider experience. This down time will last until 12:00 midnight April 15, 2013. During this time providers will not be able to enroll newborns or notify OHCA of admissions of potentially eligible members (NODOS).

All babies born during this time will be enrolled beginning April 16, 2013 and be eligible as of the child’s date of birth. NODOS’ needed during this time will be backdated. You must notify us of the need for a NODOS for April 12, 2013 through April 15, 2013 before the COB on April 18, 2013.

4/9/2013

Registration for 2013 Enid Spring Workshop

Title: Registration for 2013 Enid Spring Workshop

Run Date: 04/09/2013 – 04/18/2013

PV Type: All

Registration for the April 18, 2013 Spring Workshop for Enid will close on Thursday, April 11th at 5 p.m. Registration for locations in OKC and Tulsa are still available. This workshop is going to be very large in numbers and many classes are already closed, so please make sure you are only registered for the classes that pertain to you and will attend. We will not be able to allow walk-in registration for these workshops. Each attendee must have their own registration and please thoroughly read the class descriptions and recommended audiences before choosing your classes. Register today!

As mentioned in provider letter 2013-03 primary care providers can qualify for enhanced payments for E&M and Vaccine Administration services beginning January 1, 2013. We know many physicians have not completed the necessary documents to qualify. (Nurse practitioners and physician assistants should contact their supervising physicians to see if they qualify.) We want to make sure you get the enhanced payment for the services you provide. Our first reconciliation payment has been delayed until next month to allow more providers time to attest. PLEASE review the information on our public website, review the dear provider letter and if you have any additional questions please call 1-800-522-0114 option 5.

This message is regarding services for cell-free fetal DNA testing billed to members served by the Oklahoma Health Care Authority (OHCA). These tests may be marketed under trade names including MaterniT21 (Sequenom),Harmony (LabCorp/Ariosa), Panorama (Bio-Reference Labs/Quest/Natera), or Verifi (Verinata). The list prices for these tests range from ~$800 to ~$2,700.

While we recognize the value of genetic testing when such testing has a direct impact on clinical outcomes and is fully evaluated, accepted, and incorporated into evidence-based guidelines, we have determined that the aforementioned tests do not meet this threshold. Therefore, these tests are not compensable services, and members will be responsible for any charges resulting from cell-free fetal DNA testing services.

Registration for the April 11 2013 Spring Workshop for Durant will close today, April 3rd at 5 p.m. Registration for locations in Enid, OKC and Tulsa are still available. This workshop is going to be very large in numbers and many classes are already closed, so please make sure you are only registered for the classes that pertain to you. We will not be able to allow walk-in registration for these workshops. Each attendee must have their own registration and please thoroughly read the class descriptions and recommended audiences before choosing your classes. Register today!

OHCA is now accepting EHR attestations for the 2013 EHR participation year. For a synopsis of the changes please go to http://www.okhca.org/2013-EHR-Changes. If you have additional questions, please contact Melissa Clampitt at 405-522-7567.

4/1/2013

Potential Denials for K0001 for March 2013

Title: Potential Denials for K0001 for March 2013

Run Dates: 3/29/13 thru 6/30/13

PV Types: 250 – DME/Medical Supply Dealers

Due to the OHCA system setting, there is a probability that you have received denials for March 2013 claims for K0001 rental episodes.

The OHCA system was set to require 30 calendar days between claims – see example:

Date of Service - February 10, 2013 (18 days in February)

Date of Service – March 13, 2013 (12 days in February – 30 days have elapsed – use a date after March 13, 2013 and prior to March 31, 2013 for the March date of service.

The OHCA system has been corrected to allow one claim per calendar month beginning in April 1, 2013 for the K0001 code. You may bill the April date of service using your normal billing date.

OHCA will begin accepting EHR attestations Monday, April 1st, for the 2013 EHR participation year. For a synopsis of the changes please go to http://www.okhca.org/2013-EHR-Changes. If you have additional questions, please contact Melissa Clampitt at 405-522-7567.

THE NEW SOONERCARE PROVIDER PORTAL WILL BE INTRODUCED AT THE 2013 SPRING PROVIDER TRAINING WORKSHOP!

ALL PROVIDERS are encouraged to attend the Spring 2013 SoonerCare Provider Training Workshops hosted by the Oklahoma Health Care Authority (OHCA) and HP Enterprise Services. Workshops will include training on the new SoonerCare Provider Portal (formally the Secure Site) as well as Behavioral Health training. These workshops will be held in 4 locations, beginning April 11th.

Beginning December 21, 2012 OHCA made changes to its call center operations. For faster service, please use OHCA’s SoonerCare Secure web site or Member Eligibility Verification Voice Response System for all claims status and eligibility inquiries. Thank you for your cooperation.

Please make sure all parties involved with Claims submission and eligibility verification have access to your secure site and EVR information.

Due to changes in the OHCA Call Center the SC-13 form, Provider Change Request form, has been updated to reflect a new fax number. The new fax number is now (405) 917-7374.

The new SC-13 form is accessible on the OHCA public website, www.okhca.org, under “Forms”. Medical Home providers need to replace any copies of the old SC-13 form and replace it with the new form (revision date March 1, 2013) beginning February 28, 2013.

SC-13 forms faxed to the obsolete FAX#, (405) 782-8780, will not be processed after February 27, 2013.

OHCA and HP Enterprise Services are excited to announce a medical authorization webinar training. This is a general overview of the medical PA (does not include Dental, BH or Pharmacy) submission process. The recommended audience would be any SoonerCare provider needing a general overview of the PA submission process.

1. The referral document must include the type(s) of therapy services requested (e.g., “speech evaluation and treatment”, “speech-language evaluation”, etc.).2. Medical diagnosis (if available) may be included on the referral document; treatment diagnosis should be included in evaluation report/treatment plan.3. Frequency & duration recommendations may be contained within the evaluation report/treatment plan documentation. 4. The referral/script MUST identify the specific service(s) ordered (for example, “speech services” is not sufficient.5. A signed referral and/or prescription must be obtained PRIOR to performing any service; and must be signed and dated by the physician, PA, or ARNP before any service is provided. 6. The evaluation cannot occur on the same day the referral or script was signed by the physician.7. A new script or referral must be obtained for each evaluation (including re-evaluations). Copies of the script and/or referral must be submitted as part of the required documentation for each prior authorization request.8. The GN modifier must be included on the HCA12a line item for 92506 as well as the line item(s) for any therapy services requested.Refer to letter 2013-05 for acceptable referral documents and instructions.

2/26/2013

All Medical Home Providers

All Medical Home Providers

Due to changes in the OHCA Call Center the SC-13, Provider Change Request form, will be updated to reflect a new fax number. The new fax number will be (405) 917-7374. Medical Home providers will need to replace any copies of the current SC-13 form with the new form (revision date 3-1-13) beginning Feb. 28th, 2013. Please continue to use the current form until then. SC-13 forms faxed to the old number of (405) 782-8780 will not be received after Feb. 27th 2013.

2/19/2013

Prior Authorization Requests

Title: Prior Authorization Requests

Run Date: 2/19/13 – 05/05/13

PV Types: All

Message:

Effective April 1, 2013, the Medical Authorization Unit (MAU) will no longer pend for additional documentation to providers submitting incomplete / incorrect prior authorization requests (PARs). All incomplete / incorrect PARs will be cancelled and the provider will be required to submit a new PAR. The 30-day-retro rule will remain in effect for all PARs submitted to the MAU. For all PAR-related questions, please call the OHCA Call Tree at (800)522-0114.

When using nucleic acid amplification techniques to test for a single infectious organism that lacks a specific CPT code in the 87470-87660 range, billing a single unit of CPT code 87798 is appropriate. When nucleic acid amplification techniques are used to test for more than one infectious organism in a specimen, whether or not a specific CPT code in the 87470-87660 range is available (such as in an infectious disease panel), billing a single unit of CPT code 87801 is appropriate.

OHCA has determined that billing multiple units of CPT code 87798 rather than a single unit of 87801 has led to incorrect reimbursement of services, denial of services, overpayments, and recoupments. OHCA will allow only one unit of 87798 or 87801 for single or multiple-organism tests, respectively, to ensure that infectious disease testing services are paid appropriately.

As you may be aware, CPT codes 87631-87633 were introduced in 2013 for procedures that detect multiple respiratory viruses in a single multiplex reaction. These codes are not covered services at this time.

2/6/2013

NPI Crosswalk Webinar

Title: NPI Crosswalk Webinar

Run Date: 02/06/2013 – 02/22/2013

PV Types: All

OHCA and HP will host a NPI Crosswalk webinar on February 21, 2013 at 2:30 p.m.

This webinar will detail how to appropriately crosswalk an NPI number to the appropriate Medicaid billing or rendering ID and the appropriate legacy provider ID number. Additional information (when needed) such as zip+4, contract code and taxonomy code details will be discussed.

Note: This Webinar is intended for those that bill electronically NOT for providers who are submitting claims directly on the SoonerCare Secure Website. NPI Crosswalk for Medicare Crossover claims will not be discussed in this presentation.

Beginning January 31, 2013 you can call OHCA to determine if a member has had previous testing within the last year.

Call 405-522-7055. OHCA staff will be able to assist. If you need to leave a message, we will call back as soon as possible.

If you have any questions Please call the OHCA call center at 1-405-522-0114.

1/31/2013

Speech PA Requirement Global

Speech PA Requirement Global

A Prior authorization is required for ALL speech therapy services including evaluations. Providers must submit a Prior Authorization Request for the evaluation and requested therapy services along with a copy of the physician’s prescription, OHCA form SC-10, or hospital or clinic’s referral form indicating the specific service(s) for which member has been referred. The referral/order must be signed and dated by the physician, PA, or ARNP prior to the date of the evaluation.

1/28/2013

Skilled Nursing Facility Part-A Crossover Claims

Title: Skilled Nursing Facility Part-A Crossover Claims

Run Date: 01/29/2013 – 03/15/2013

PV Types: 30 – Nursing Facility 35 – Skilled Nursing

Dear Nursing Facility Provider:

The Governor has approved rule changes allowing the OKHCA to pay 100% of the deductibles and co-insurance on Medicare Skilled Nursing Facility Part –A Crossover Claims. This message is to notify you of this change for services rendered February 1, 2013 and after.

The crossover claims file automatically and this requires only a change on our part, which has been made. Thank you for your services.

SoonerCare’s Population Care Management (PCM) Department offers a wide variety of services for SoonerCare members. This webinar will provide orientation to the structure of the department and the services offered by the three work units in the PCM department. We will explore available services such as Obstetrical-related Case Management, Pediatric-related Case Management, Out of State coordination, ER Utilization management and Social Service Coordination. We will also discuss our chronic care initiatives managed through our Chronic Care Unit and Health Management Program.

This webinar will be particularly helpful for primary care providers and their practice staff such as case managers, referral coordinators and office nurses. The information will also be helpful to staff of specialty provider offices, particularly OB practices and those focused on chronic illness. This webinar is limited to the first 75 registrants.

This webinar will provide orientation to the structure of the department and the services offered by the three work units in the PCM department. We will explore available services such as Obstetrical-related Case Management, Pediatric-related Case Management, Out of State coordination, ER Utilization management and Social Service Coordination. We will also discuss our chronic care initiatives managed through our Chronic Care Unit and Health Management Program.

This webinar will be particularly helpful for primary care providers and their practice staff such as case managers, referral coordinators and office nurses. The information will also be helpful to staff of specialty provider offices, particularly OB practices and those focused on chronic illness.

Oklahoma SoonerCare 101 is designed to educate office staff about billing and procedural aspects of Oklahoma SoonerCare. There are two classes in a one-session format: Introduction to Oklahoma SoonerCare and the Provider Secure Site. Class curriculum is applicable to all provider types.

These sessions are held in Oklahoma City and Muskogee on the first Thursday every other month.

This message clarifies billing requirements for claims involving molecular pathology CPT codes in the 81200-81479 range. Because these codes are manually priced, providers will need to submit an attachment (itemized invoice of services performed) with any claims that include molecular pathology procedures. Claims involving molecular pathology procedure codes in the 81200-81479 range that are submitted without an attachment will be automatically denied.

OHCA is currently upgrading its EHR attestation system to accommodate the changes for the 2013 participation year. Until further notice, we are unable to accept any attestations for the 2013 participation year. We apologize for any inconvenience.

For those eligible professionals that still need to submit attestations for the 2012 participation year may continue to do so.

1/2/2013

2013 New Call Center Hours

Title: 2013 New Call Center Hours

TO: All Providers

Run Dates: 01/02/2013 – 02/17/2013

Due to changes in call center operations, the hours for the provider customer service unit will change from 7:30am -5:30pm to 8:00am to 5:00pm effective January 2, 2013. OHCA apologizes for any inconvenience this change in business hours might cause. Thank you for your continued service to Oklahoma SoonerCare members.